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A PBO Phase III Case Report
Treatment of Class I Bimaxillary Protrusion Ernesto Jose G. de Leon, DMD Dr. Ernesto Jose G. G. de Leon graduated from the Centro Ce ntro Escolar University in 1985 and a nd underwent the orthodontic orthodonti c preceptorship under the late Dr. Luz C. Macapanpan in 1994 - 1995. He took up the MEAW Course given by the MEAW Study Club of the Philippines from August to November 2003. He sucessfully participated in the PBO Phase III Case Presentation 2004 Examination of which the following was one of the cares presented. A case report is presented of an Angle Class I bimaxillary protrusion with high mandibular plane angle which was treated with four 1 st bicuspids extraction and Straightwire Archwire Mini-Wick Appliance.
Figure 1. Patient R.Y. : Pretreatment extraoral and intraoral photographs. 1
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Case Report
Figure 2. Pre-treatment cephalogram
Patient R.Y. is a female 10 years 10 months of age. The patient has characteristic Chinese features and presents with a Class I, bimaxillary protrusion malocclusion with protruded lips and convex profile. Mild lower crowding is present with a moderate overbite of 4mm and an overjet of 5.5mm. The curve of Spee is moderate as well. Being young, a good amount of growth is expected of this patient. It was noted that mild facial asymmetry is present with the chin shifted to her left. (Figure 1) Cephalometric analysis revealed a Class I skeletal relationship with an ANB of 2.5 degrees and AO-BO of -.5mm. Vertical height appears normal. (Figure 2) The maxillary
Table 1 Patient R.Y. female, 10:10
and mandibular incisors are labially flared and positioned more labial in their denture bases. The upper incisors shows
Mean X
Pre TX
more procumbency (U1-NA= 11.5mm and 36.5 degrees) than
BA-S-N
130 deg.
136
the lower. (Table 1)
SNA
84.5 deg.
76
NA-FH
90 deg.
88.5
SNB
82 deg.
73.5
ANB
2.5 deg.
2.5
AO-BO
-1 to 1 mm
-.5
SN-MP
31.3 deg.
36.5
FMA
28.7 deg.
24.5
History and Etiology:
In this case, it is the mother who complained of her daughter’s teeth and lips of being too protruded. Treatment Plan:
1. Extraction of all upper and lower 1st premolars. The
UI-Apog
8.6 mm
13
first bicuspids were extracted rather than the second
UI-NA
6.4 mm
11.5
because of the apparent protrusiveness of both
UI-NA
24.7 deg.
36.5
upper and lower incisors. The convex profile was
LI-NB
7.5 mm
9
also a major concern, particularly to the mother.
LI-NB
29.8 deg.
29
UI-LI
122.8 deg.
112.5
2. Full upper and lower orthodontic treatment with .018 Mini-Wick Appliance, Alexander prescription. 3. Debond/deband before retaining with upper Hawley and lower fixed retainers.
LIip-Eline
-2 mm
+5
The Specific Objectives of Treatment (A-P, Transverse, Vertical)
Maxilla: Reduce A-P length with moderate level of anchorage 2
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Maintain transverse relationship
II elastics (1/4 in X 6 oz.) were started to help obtain
Minimize opening of the bite by controlling molar
improved interdigitation and Class I relations.
extrusion Mandible: Reduce A-P length with moderate level of anchorage Maintain transverse relationship Maintain vertical relation by controlling molar extrusion to avoid clockwise mandibular rotation
6. Final archwire of .017 X .025 & .016 X .022 SS were placed on the upper and lower arches respectively. 7. All brackets and bands were removed after 28 months of active treatment on October 19, 2001. 8. Retainers were delivered one week after debonding procedure.
Maxillary Dentition: Retract and upright anterior teeth Level and align Mandibular Dentition:
Results Achieved (A-P, Transverse, Vertica l) Figure 3,4
Maxilla: The A-P length was reduced
Retract anterior teeth and maintain axial inclination
Transverse dimensions were controlled and
Level and align
maintained.
Occlusion: Achieve proper overbite and overjet
Vertical relation has been maintained as well. Mandible:
Maintain Class I cuspid and molar relationships
The A-P length was reduced
Obtain canine and incisal guidances
Transverse dimensions were maintained.
Maintain dental midlines
Clockwise rotation of the mandible was avoided
Facial Esthetics: Improve facial balance Improve smile esthetics
by careful control of molar extrusion. Maxillary Dentition: The anteriors were all retracted and brought to a more upright position.
Treatment Progress / Mechanotherapy:
1. All four 1st premolars were extracted. (Figure 5a) 2. All molars were banded 2 weeks after extraction
All teeth were leveled and aligned. Mandibular Dentition: The lower incisor were retracted and their axial
procedure. Upper and lower .018 Mini-Wick
inclinations were maintained
brackets were installed. Initial alignment was
All teeth were leveled and aligned
carried out with .016 NiTi June 04, 1999. 3. Upper canines were distalized through sliding mechanics using elastomeric chain on .016 SS wire. 4. Lower incisors were retracted en masse with .016 X .022 Vari-Simplex SS Closing Loop archwire. 5. After space closure, arches were releveled with plain .016 X .022 preformed VSD archwire. Class
Occlusion: Proper overbite and overjet were obtained Class I cuspid and molar relations were achieved Incisal and canine guidances were established Dental midlines were maintained Facial Esthetics: Facial balance is very much improved. 3
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Patient’s profile and smile demonstrates
Figure 4. Post treatment Cephalometric
tremendous improvement. (Figure 3) Retention:
Upper and lower retainers were delivered one week after debonding. Full-time wear was advised for 12 months and then nighttime for another 6 months. Evaluation of third molar removal recommended to be done one year after retention.
Figure 3. Post retention facial and intra-oral photograph 4
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Table 2. Patient R.Y. Female, 13:11
Final Evaluation of Treatment:
Downward and forward growth is clearly demonstrable Mean X
Post - tx
in this patient. There was lengthening of the ramus due to
BA-S-N
130 deg.
136
condylar growth. The symphysis has grown down as well.
SNA
84.5 deg.
75
Composite tracing shows that the anteriors were truly retracted
NA-FH
90 deg.
87
successfully to provide soft tissue relief and establish facial
SNB
82 deg.
74
balance and harmony (Fig. 6).
ANB
2.5 deg.
1.0
AO-BO
-1 to 1 mm
-4.5
to successful orthodontic treatment. Comparing the post-
SN-MP
31.3 deg.
36
treatment results with the pre-treatment records reveals that
FMA
28.7 deg.
22.5
the treatment objectives set in this case were achieved. The
UI-Apog
8.6 mm
9
canines and molars were maintained in Class I. Occlusion
UI-NA
6.4 mm
9.5
obtained is stable as can been from the post-retention records
UI-NA
24.7 deg.
31.5
(Fig. 3).
LI-NB
7.5 mm
5
LI-NB
29.8 deg.
30
retracted and brought to a more favorable relationship with
UI-LI
122.8 deg.
120
each other (U1-L1=112.5 deg to 122.5 deg). Upper inci-
LIip-Eline
-2 mm
+2
sors are more upright now (U1-NA=36.5 deg to 29 deg)
Good timing and proper monitoring of this case led
With orthodontic treatment, all anterior teeth were
while the inclinations of the lower incisors were maintained (Table 3).
Figure 5a. Pre-treatment panoramic radiograph
Figure 5b. Post-treatment panoramic radiograph 5
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The patient’s smile has been greatly improved and patient’s profile showed big improvement by providing har-
All third molars are to be monitored every six months until resolved (Figure 5b).
mony as a result of treatment (Fig 3). The lower lips appear
Mother and patient are very pleased with the results.
to show big improvement as well, from Llip – Eline of +5mm
Prognosis for this case to be stable is excellent. Fixed re-
to 2mm and finally to 0mm (Table 3).
tainer was removed when patient came back 3 months later.
Table 3. Cephalometric Summary Area of Study Measurement
Cranial Base Maxilla to Cranial Base Mandible to Cranial Base MaxilloMandibular Relations
Vertical Height Maxillary And Mandibular Incisor Position Soft Tissue
Standard
Pre-tx Age
Progress
BA-S-N SNA NA-FH SNB
10:10 130 deg. 84.5 deg. 90 deg. 82 deg.
136 76 88.5 73.5
Post-tx Age 15:4 136 75 87 74
ANB AO-BO SN-MP FMA UI-Apog UI-NA UI-NA LI-NB LI-NB UI-LI LIip-Eline
2.5 deg. -1 to 1 mm 31.3 deg. 28.7 deg. 8.6 mm 6.4 mm 24.7 deg. 7.5 mm 29.8 deg. 122.8 deg. -2 mm
2.5 -.5 36.5 24.5 13 11.5 36.5 9 29 112.5 +5
1.0 -4.5 36 22.5 9 9.5 31.5 5 30 120 +2
13:11
1-yr. Post-Tx Age 137 74 88.5 72.5 1.5 -4.5 38.5 23.5 8 7 29 5 28 122.5 0
References 1. Graber TM; Vanarsdall RL, Jr: Diagnosis and Treatment Planning in Orthodontics, Orthodontics-Current Principles and Techniques, 1994. Mosby-Year Book, Inc. 2. Alexander RG: The Use of Elastics and Other Extra-Oral Appliances in the Vari-Simplex Discipline, The Alexander Discipline, 7:149-165, 1986.
Figure 6. Superimpositions of cephalometric tracings before and after treatment. _________ Pre-treatment ______ Post-treatment 6
3. Alexander RG: The Vari-Simplex Discipline - Part 3Extraction Treatment, J Clin Ortho pp. 537-547, August 1983.
